Situations that prompt teachers in problem-based curricula to reflect on their beliefs, identity and mission.

Teachers have different perceptions of how to enhance student learning. Whereas some take a teacher-centred perspective, others lean more towards a student-centred approach. Many studies in higher education have invoked Korthagen's onion model (2014) to explain how teachers' perspectives can impact their teaching practices. Spanning six interrelated layers, this model contains both outer (environment, behaviour, competencies) and inner (beliefs, identity, and mission) aspects. Focusing essentially on teachers' outer aspects, previous studies have paid scant attention to how particular situations affect teachers' inner aspects and, consequently, how teachers perceive student-centred learning. In this descriptive qualitative study, we explored situations that encouraged or discouraged teachers to embrace student-centred beliefs, identities and missions. We held three focus-group discussions with 18 teachers from two Indonesian medical schools, performing a thematic analysis of the data thus obtained. We found that certain situations made teachers reflect on their inner aspects, which either favourably or adversely affected their acceptance of a student-centred learning approach. Teachers' outer aspects (i.e. their prior problem-based teaching and learning experiences, learning situations from their own training as well as clinical duties) strongly interacted with their inner aspects, thereby shaping their teaching perspectives. Understanding how specific situations can influence teachers' inner aspects might help institutions to design faculty development programmes that address teachers' specific educational needs.

Continuous enhancement of educational quality - fostering a quality culture: AMEE Guide No. 147.

Internal quality assurance (IQA) is one of the core support systems on which schools in the health professions rely to ensure the quality of their educational processes. Through IQA they demonstrate being in control of their educational quality to accrediting bodies and continuously improve and enhance their educational programmes. Although its need is acknowledged by all stakeholders, creating a system of quality assurance has often led to establishing a 'tick-box' exercise overly focusing on quality control while neglecting quality improvement and enhancement. This AMEE Guide uses the concept of quality culture to describe the various dimensions that need to be addressed to move beyond the tick-box exercise. Quality culture can be defined as an organisational culture which consists of a structural/managerial aspect and a cultural/psychological aspect. As such this AMEE Guide addresses tools and processes to further an educational quality culture while also addressing ways in which individual and collective awareness of and commitment to educational quality can be fostered. By using cases within health professions education of both formal and informal learning settings, examples will be provided of how the diverse dimensions of a quality culture can be addressed in practice.

The imperative for (and opportunities of) research on adaptive expertise in health professions education.

In this editorial, three Advances in Health Sciences Education editors argue for the importance and impact of adaptive expertise on the future of health professions education and work. They present a sample of the broad range of theory-informed research currently contributing to understanding and applying adaptive expertise in health professions education. They reflect on the unique opportunities that interdisciplinarity offers this endeavour. Finally they offer potential ways forward for continued efforts to advance collective understanding of education, expert development and health professions practice.

Task-based training to prevent surgical site infection: A formative evaluation.

Background: Lack of evidence-based training constitutes a serious impediment to preventing surgical site infections in low-middle income countries (LMIC). The purpose of this study was to design and implement an infection prevention training programme and investigate how it might work in an LMIC. Intended for healthcare professionals working in operating rooms, the programme was based on current instructional design principles of interprofessional, task-based learning. The second aim was to carry out a formative evaluation exploring participants' and facilitators' perceptions and experiences of the training. Methods: In undertaking this design-based research, we used a mixed-methods approach. The four session training was attended by anaesthesia and surgical trainees, registered nurses, technologists and included a video showing best practices, role plays, and peer-group reflection. We evaluated the programme through questionnaires, focus-group interviews with participants, written reflections by participants, and individual interviews with facilitators. Quantitative analysis was complemented by thematic analysis of focus-group and interview transcripts, reflections, and observer notes. Results: Our analysis revealed that participants had positive attitudes towards the training. They felt they had learned a lot from each other and the facilitators offered them the opportunity to interact with each other. Trainees especially valued the video presentation as it inspired them to revise old concepts and presented an excellent practical example of infection prevention in their specific setting. Conclusion: The training seemed to bridge the gap between knowledge and practice. However, direct observation of procedural skills and peer feedback could further reduce the gap, by enhancing the transfer of knowledge to practice.

Creativity: A viable and valuable competency in medicine? A qualitative exploratory study.

PURPOSE: To explore and describe medical students, postgraduate medical trainees, and medical specialists' perceptions of creativity, the importance they attach to creativity in contemporary healthcare, and, by extension, how they feel creativity can be taught in medical education. METHODS: The authors conducted seven semi-structured focus groups with medical students (n = 10), postgraduate medical trainees (n = 11) and medical specialists (n = 13). RESULTS: Participants had a trifurcated perception of creativity, which they described as a form of art that involves thinking and action processes. Facing complex patients in a rapidly changing healthcare landscape, doctors needed such a multifaceted perspective to be able to adapt and react to new and often complex situations that require creativity. Furthermore, participants identified conditions that were perceived to stimulate and inhibit creativity in healthcare and suggested several techniques to learn creativity. CONCLUSION: Participants perceived creativity as a form of art that involves thinking and action processes. Creativity is important to tackle the challenges of current and future workplaces, because it stimulates the search for original solutions which are needed in a rapidly changing healthcare landscape. Participants proposed different methods and techniques to promote creativity learning. However, we need further research to design and implement creativity in medical curricula.

Creation and evaluation of a novel, interdisciplinary debriefing program using a design-based research approach.

BACKGROUND: The emergency department (ED) witnesses the close functioning of an interdisciplinary team in an unpredictable environment. High-stress situations can impact well-being and clinical practice both individually and as a team. Debriefing provides an opportunity for learning, validation, and conversation among individuals who may not typically discuss clinical experiences together. The current study examined how a debriefing program could be designed and implemented in the ED so as to help teams and individuals learn from unique, stressful incidents. METHODS: Based on the theory of workplace-based learning and a design-based research approach, the evolved nature of a debriefing program implemented in the real-life context of the ED was examined. Focus groups were used to collect data. We report the design of the debriefing intervention as well as the program outcomes in terms of provider's self-perceived roles in the program and program impact on provider's self-reported clinical practice as well as the redesign of the program based on said feedback. RESULTS: The themes of barriers to debriefing, provision of perspectives, psychological trauma, and nurturing of staff emerged from focus group sessions. Respondents identified barriers and concerns regarding debriefing, and based on this information, changes were made to the program, including offering of refresher sessions for debriefing, inclusion of additional staff members in the training, and remessaging the purpose of the program. CONCLUSIONS: Data from the study reinforced the need to increase the frequency and availability of debriefing didactics along with clarifying staff roles in the program. Future work will examine continued impact on provider practice and influence on departmental culture.

Design and evaluation of a team-based interprofessional practice placement: A design-based research approach.

INTRODUCTION: Team-based Interprofessional Practice Placements (TIPPs) are innovative training practices. Evidence to substantiate the design of TIPPs is limited. This study explores the design and evaluation of TIPPs to support undergraduate students in gaining a better understanding of the complexity of patient problems in primary care settings and of collaboration within interprofessional teams. METHOD: We implemented TIPPs at a University of Applied Sciences, Belgium based on three principles: (1) authentic tasks with real clients, (2) students collaborated in small interprofessional teams, and (3) students were supported by teachers. TIPPs were evaluated using focus groups (N = 5) that explored teachers' (N = 13) and students' (N = 22) experiences. Data were analysed thematically. RESULTS: Three themes were constructed. First, TIPPs enhance students' understanding of the complexity of clients' problems and what matters to the client. Second, TIPPs support students to value the expertise of interprofessional team members. Finally, to enhance students' learning, TIPPs must strike an appropriate balance between teacher support and student autonomy. CONCLUSION: The three design principles used to underpin the TIPPs were viable. Although students reported to receive sufficient support, they also felt this support should have been gradually withdrawn to offer more opportunities for autonomous learning. Teachers reported difficulties in balancing their support.

Applying Landscapes of Practice Principles to the Design of Interprofessional Education.

ISSUE: Although interprofessional education (IPE) is acknowledged as a way to prepare health professions students for future interprofessional collaboration (IPC), there is a need to better ground IPE-design in learning theory. Landscapes of practice and its concepts of knowledgeability and identification are suggested as a framework that may help optimize IPE. This Observation paper provides an explanation of how these concepts might be used in IPE-design. EVIDENCE: We propose using three modes of identification, i.e., engagement, imagination, and alignment, described in this framework, for an IPE-design that fosters IPC skills, professional identity formation, and knowledgeability about a field and its actors. Identification and knowledgeability are through to enable successful collaboration across professional and practice boundaries. IMPLICATIONS: Focusing on identification implies that students develop a sense of relevance to one another in solving complex problems (engagement), they become aware of their own roles and responsibilities in relation to others (imagination), and they gain awareness of the context in which the different professions align and collaborate (alignment). Altogether, this enables students to become knowledgeable in the landscape, which prepares them for successful interprofessional collaboration in practice.

The impact of interprofessional task-based training on the prevention of surgical site infection in a low-income country.

BACKGROUND: Training is considered instrumental in reducing surgical site infection. We developed training based on authentic tasks, interprofessional learning, and reflective learning for implementation in a low-income country where such training opportunities are rare. This study evaluated the results of training in terms of participants' acceptance, participants' knowledge acquisition, and their self-perceived behavior change. METHODS: We included 145 participants in the voluntary training program, comprising 66 technologists (45.5%), 43 nurses (29.7%), and 36 doctors (24.8%) from Shifa International Hospital, Islamabad, Pakistan. We measured "satisfaction" using a questionnaire at the end of the training, "knowledge" through pre-and post-intervention assessments, and "self-perceived behavior change" using a questionnaire and interviews 8 weeks post-training. RESULTS: Pre- and post-test scores showed a significant increase in knowledge. Participants were favorable to the training and eager to participate. They positively applied in practice what they had learned about preventing surgical site infection. Our qualitative data analysis revealed two categories of themes, representing the upsides of the training as it stood, and existing factors or downsides that hindered the effective transfer of learning to practice. CONCLUSION: Participants were very enthusiastic about the training format. The knowledge test showed a gain in knowledge. Moreover, participants acknowledged that their behavior toward the prevention of surgical site infection in the operating rooms had changed. The use of authentic tasks from daily clinical practice, as well as the interprofessional approach and reflection, were considered to promote the transfer of learning. Although promising, our findings also pointed to obstacles limiting the application of evidence-based knowledge, such as a shortage of supplies and conventional practices.

Design and evaluation of a learning assignment in the undergraduate medical curricula on the four dimensions of care: a mixed method study.

BACKGROUND: Chronic and palliative care are rapidly gaining importance within the physician's range of duties. In this context, it is important to address the four dimensions of care: physical, psychological, social, and spiritual. Medical students, however, feel inadequately equipped to discuss these dimensions with the patient. To bridge this gap, a new assignment was developed and implemented, in which students talked to a chronic or palliative patient about the four dimensions of care during an internship. This study, reports the evaluation of this assignment by students and teachers using a design-based approach. METHODS: Mixed methods were used, including a) student questionnaires, b) student focus groups, c) teacher interviews, and d) student's written reflections. Two researchers performed analyses of the qualitative data from the focus groups, interviews, and written reflections using qualitative research software (ALTLAS.TI). Descriptive statistics were computed for the quantitative data using SPSS 21.0. RESULTS: Students and teachers valued talking to an actual patient about the four dimensions of care. Reading and providing peer feedback on each other's reports was considered valuable, especially when it came to the diversity of illnesses, the way that patients cope and communication techniques. The students considered reflection useful, especially in the group and provided it was not too frequent. All the dimensions were addressed in the interviews, however the spiritual dimension was found to be the most difficult to discuss. The analysis of the written reflections revealed an overlap between the social and spiritual dimensions. Students pay a lot of attention to the relationship between the illness and the patient's daily life, but the reflections do often not show insight in the potential relationship between the four dimensions and decisions in patient care. CONCLUSIONS: During internships, medical students can practice talking about four dimensions of care with a chronically ill or palliative patient. Due to the format, it can be implemented across existing internships with relatively little extra time and effort. Reflection, peer feedback, and group discussion under the guidance of a teacher are important additions.

Out of sight, out of mind? A qualitative study of patients' perspectives on cross-border healthcare in a European border region.

OBJECTIVE: To improve our understanding of patients' needs in cross-border healthcare, with a specific focus on handover. METHODS: In this qualitative study, we conducted narrative interviews with 8 patients who had experienced cross-border healthcare, including handover. Based on an inductive analysis, we crafted stories representing participants' perspectives. Crafted stories attend to the personal character of patients' experiences. RESULTS: We crafted 3 stories relating patients' cross-border healthcare pathways. We identified 3 recurring issues in these stories: (1) Patient involvement in the decision-making process regarding their healthcare; (2) Communication with their healthcare providers; and (3) Information throughout the healthcare process. CONCLUSION: The said issues, albeit no novelty in healthcare, seem to be amplified by cross-border barriers, such as system, language, and cultural differences. To empower patients to be involved in their own healthcare process, these issues should become a topic of conversation between patients and healthcare professionals. PRACTICE IMPLICATIONS: The patient stories in this article could help raise awareness among professionals and patients about the issues patients face in cross-border healthcare. Awareness is a first step in overcoming these issues.

Collaborative learning: Elements encouraging and hindering deep approach to learning and use of elaboration strategies.

AIM: The purpose of this research was to investigate students' approaches to learning and use of cognitive strategies in a collaborative learning environment with team-based learning. METHOD: In a mixed-methods study, 263 medical students from 6 different semesters answered the R-SPQ-2F Questionnaire and MSLQ's items that measure elaboration and rehearsal strategies. ANOVA was used to compare differences between semesters, and Pearson's correlation to investigate how approaches to learning, cognitive strategies, and academic achievement correlate. Focus groups elucidated which elements in the collaborative learning environment enhanced or hindered deep approach to learning or elaboration strategies and why. RESULTS: Students took a deep approach to learning and sometimes a surface approach. They used elaboration and rehearsal strategies. First semester's students had significantly higher deep approach than fifth and sixth semesters' students. Elaboration strategies significantly correlated with final grade. Commitment to the group, case discussions, feeling challenged by teachers, and patients' visits were perceived to enhance deep approach to learning and use of elaboration strategies, while overload in course activities hindered deep approach to learning. CONCLUSIONS: Particular elements of the learning environment triggered students to take deep approach to learning and use elaboration strategies, and this positively correlated to academic achievement.

Promoting positive perceptions of and motivation for research among undergraduate medical students to stimulate future research involvement: a grounded theory study.

BACKGROUND: Research is of great value to make advancements within the medical field and, ultimately, offer the best possible patient care. Physician-scientists are key in contributing to the development of medicine, as they can bridge the gap between research and practice. However, medicine currently faces a physician-scientist shortage. A possible solution to cultivate physician-scientists is to engage medical students in research in early phases of medical school. Evidence-based strategies to stimulate positive perceptions of and motivation for research among students could help to enhance research engagement. Consequently, understanding of students' perceptions of and motivation for research is needed. Therefore, this study aimed to identify conditions under which students develop positive perceptions of and motivation for research by answering the following sub-questions: 1) how do first-year medical students perceive research? and 2) which factors contribute to motivation or demotivation for conducting research? METHODS: We conducted a qualitative study with individual interviews using a grounded theory approach, involving 13 purposively sampled first-year medical students at Leiden University Medical Center. RESULTS: Our results suggest that first-year students are already able to identify many aspects of research. Students elaborated on the relevance of research for professional practice and personal development. Furthermore, our results suggest a relationship between perceptions of and motivation for research. Some perceptions were identical to motivating or demotivating factors to conduct research, like the relevance of research for practice and performing statistics respectively. Other motivating factors were, among others, acknowledgment, autonomy, and inspiring role models. Demotivating factors were, among others, lack of autonomy and relevance, and inadequate collaboration. CONCLUSIONS: Our results contribute to the idea that perceptions of research are related to motivation for research, which offers possibilities for interventions to promote motivation for research by making use of student perceptions of research. Consequently, practical implications to stimulate research engagement in early phases of medical school are provided. Moreover, the results contribute to existing motivational theories like Theory of Planned Behavior and Self-Determination Theory within this specific domain.

Shaping a Culture for Continuous Quality Improvement in Undergraduate Medical Education.

PURPOSE: This study sought to identify key features of an organizational quality culture and explore how these features contribute to continuous quality improvement of undergraduate medical education. METHOD: Between July and December 2018, researchers from Maastricht University in the Netherlands conducted a multicenter focus group study among 6 education quality advisory committees. Participants were 22 faculty and 18 student representatives affiliated with 6 medical schools in the Netherlands. The group interviews focused on quality culture characteristics in relation to optimizing educational development, implementation, evaluation, and (further) improvement. Template analysis, a stepwise type of thematic analysis, was applied to analyze the data. RESULTS: Five main themes resembling quality culture constituents to continuous educational improvement were identified: (1) fostering an open systems perspective, (2) involving stakeholders in educational (re)design, (3) valuing teaching and learning, (4) navigating between ownership and accountability, and (5) building on integrative leadership to overcome tensions inherent in the first 4 themes. A supportive communication climate (which can be fueled by the organization's leaders) contributes to and is integrated within the first 4 themes. CONCLUSIONS: The results call for a shift away from static quality management approaches with an emphasis on control and accountability toward more flexible, development-oriented approaches focusing on the 5 themes of a culture for continuous quality improvement. The study provides new insights in the link between theory and practice of continuous quality improvement. Specifically, in addition to quality management systems and structures, faculty's professional autonomy, collaboration with peers and students, and the valuing of teaching and learning need to be amplified.

A National, Palliative Care Competency Framework for Undergraduate Medical Curricula.

As nearly all doctors deal with patients requiring palliative care, it is imperative that palliative care education starts early. This study aimed to validate a national, palliative care competency framework for undergraduate medical curricula. We conducted a Delphi study with five groups of stakeholders (palliative care experts, physicians, nurses, curriculum coordinators, and junior doctors), inviting them to rate a competency list. The list was organized around six key competencies. For each competency, participants indicated the level to which students should have mastered the skill at the end of undergraduate training. Stability was reached after two rating rounds (N = 82 round 1, N = 54 round 2). The results showed high levels of agreement within and between stakeholder groups. Participants agreed that theoretical knowledge is not enough: Students must practice palliative care competencies, albeit to varying degrees. Overall, communication and personal development and well-being scored the highest: Junior doctors should be able to perform these in the workplace under close supervision. Advance care planning scored the lowest, indicating performance in a simulated setting. A wide range of stakeholders validated a palliative care competency framework for undergraduate medical curricula. This framework can be used to guide teaching about palliative care.

Going the extra mile - cross-border patient handover in a European border region: qualitative study of healthcare professionals' perspectives.

BACKGROUND: Cross-border healthcare is complex, increasingly frequent and causes potential risks for patient safety. In this context, cross-border handovers or the transfer of patients from one country to another deserves particular attention. Although general handover has been the topic of extensive research, little is known about the challenges of handover across national borders, especially as perceived by stakeholders. In this study, we aimed to gain insight into healthcare professionals' perspectives on cross-border handover and ways to support this. METHODS: We conducted semistructured interviews with healthcare professionals (physicians, nurses, paramedics and administrative staff) in a European border region to investigate their perspectives on cross-border handover. The interviews were aimed to investigate settings of acute and planned handover. Informed by the theory of planned behaviour (TPB), interviews focused on participant perspectives. We summarised all interviews and inductively identified healthcare professionals' perspectives. We used elements of the TPB as sensitising concepts. RESULTS: Forty-three healthcare professionals participated. Although respondents had neutral to positive attitudes, they often did not know very well what was expected of them or what influence they could have on improving cross-border handover. Challenges covered five themes: information transfer, language barriers, task division and education, policy and financial structures and cultural differences. To overcome these challenges, we proposed strategies such as providing tools and protocols, discussing and formalising collaboration, and organising opportunities to meet and get to know each other. CONCLUSION: Healthcare professionals involved in cross-border handovers face specific challenges. It is necessary to take measures to come to a shared understanding while paying special attention to the above-mentioned challenges. Meeting in person around meaningful activities (eg, training and case discussions) can facilitate sharing ideas and community building.

Mind the gap: Teachers' conceptions of student-staff partnership and its potential to enhance educational quality.

Introduction: Student-staff partnerships as a concept to improve medical education have received a growing amount of attention. Such partnerships are collaborations in which students and teachers seek to improve education by each adding their unique contribution to decision-making and implementation processes. Although previous research has demonstrated that students are favourable to this concept, teachers remain hesitant. The present study investigated teachers' conceptions of student-staff partnerships and of the prerequisites that are necessary to render such partnerships successful and enhance educational quality.Method: We conducted semi-structured interviews with 14 course coordinators who lead course design teams and also teach in 4 bachelor health programmes, using Bovill and Bulley's levels of student participation as sensitising concepts during data analysis.Results: The results pointed to three different conceptions of student-staff partnerships existing among teachers: Teachers teach and students study; teachers teach and value students' feedback; and teachers and students co-create. The prerequisites for effective co-creation teachers identified were: Teachers must be open to involve students and create dialogues; students must be motivated and have good communication skills; the organisation must be supportive; and teachers should have the final say.Conclusion: We conclude that teachers' conceptions are consistent with Bovill and Bulley's levels of student participation. Under certain conditions, teachers are willing to co-create and reach the highest levels of student participation.

A review to identify key perspectives in PBL meta-analyses and reviews: trends, gaps and future research directions.

In the past 50 years, the original McMaster PBL model has been implemented, experimented, revised, and modified, and is still evolving. Yet, the development of PBL is not a series of success stories, but rather a journey of experiments, failures and lessons learned. In this paper, we analyzed the meta-analyses and systematic reviews on PBL from 1992 to present as they provide a focused lens on the PBL research in the past 5 decades. We identified three major waves in the PBL research development, analyzed their impact on PBL research and practice, and offered suggestions of research gaps and future directions for the field. The first wave of PBL research (polarization: 1990-mid 2000) focused on answering the question "Does PBL work?" and the outcomes. The results were conflicting. The researchers took polarizing positions and debated over the merits of PBL throughout this wave. However, the contradictory results and the debates in fact pushed the researchers to look harder for new directions to solve the puzzle. These efforts resulted in the second wave (from outcomes to process: mid 2000-mid 2010) that focused on the question "How does PBL work?" The second wave of PBL research targeted at investigating the effects of implementation constituents, such as assessment formats or single versus curriculum wide implementations. The third wave (specialization: mid 2010 and onward) of PBL research focused on "How does PBL work in different specific contexts?" These research widened our perspectives by expanding our understanding of how PBL manifests itself in different contexts. Given the diversification of PBL and more hybrid PBL models, we suggest "Why does PBL with particular implementation characteristics for specific outcomes work or not work in the condition where it is implemented?" to be the question to answer in the next wave of PBL research.

How theory and design-based research can mature PBL practice and research.

Many educational institutions in higher education switched to problem-based learning (PBL) in the last 5 decades. Despite its' successful implementation worldwide, many institutions still encounter problems in their daily teaching practices that limit deep learning in students. This raises the question: How else can we look at PBL practice and research? The main argument of this reflective paper is to better align PBL practice with the theories or principles of contextual, constructive, self-directed and collaborative learning. This paper explains what these principles or theories are. In addition, it discusses a new way to bridge theory and practice: design-based research (DBR), which combines redesigning theory-based teaching practices with investigating these practices in close collaboration with various stakeholders. There is no one-size-fits-all solution to address the problems encountered in PBL. We should be very careful in drawing conclusions about which PBL approach works best. No single solution works optimally under all conditions. At most, DBR can help us gain better insight into why PBL with certain characteristics, preferably based on theory, might work in a specific context with particular goals in mind.